Provider Demographics
NPI:1356635239
Name:THOMAS R. WIKSTROM, MD, PA
Entity Type:Organization
Organization Name:THOMAS R. WIKSTROM, MD, PA
Other - Org Name:THOMAS R. WIKSTROM, MD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PSYCHIATRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:R
Authorized Official - Last Name:WIKSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-396-0425
Mailing Address - Street 1:6817 SOUTHPOINT PKWY
Mailing Address - Street 2:SUITE 2503
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-6282
Mailing Address - Country:US
Mailing Address - Phone:904-396-0425
Mailing Address - Fax:904-396-0448
Practice Address - Street 1:6817 SOUTHPOINT PKWY
Practice Address - Street 2:SUITE 2503
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-6282
Practice Address - Country:US
Practice Address - Phone:904-396-0425
Practice Address - Fax:904-396-0448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-08
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME521612084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE22425Medicare UPIN
FLFL019AMedicare PIN